32 PHILIPP J OPHTHALMOL VOL 32 NO. 1 JANUARY - JUNE 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

CASE REPORT

PHILIPPINE JOURNAL OF

Ophthalmology JANUARY – JUNE 2007VOL. 32 • NO. 1

ABSTRACT

ObjectiveTo determine the effectiveness of transpupillary thermotherapy (TTT) in

treating patients with chronic central serous chorioretinopathy (CSC).

MethodsThis is a prospective, interventional, case series of four patients with CSC

of at least 4 months’ duration (mean of 10 months, range 7 to 16) who under-went subthreshold TTT to the leakage site. The main outcome measures wereangiographic resolution of CSC, best-corrected visual acuity (BCVA), visual-field test, number of treatments required, and development of treatment-related complications.

ResultsAll patients experienced resolution of CSC using TTT. The BCVA and visual-

field tests either improved or remained stable in all patients. The mean numberof treatments was 1.5 (range 1 to 3). No treatment-related complications wereobserved.

ConclusionTTT is a potentially safe and effective treatment for chronic CSC. A larger

randomized controlled study is needed to compare TTT with the naturalhistory of CSC and other treatment modalities.

Keywords: Central serous chorioretinopathy, Lasers, Retinopathy, Transpupillary thermotherapy

PHILIPP J OPHTHALMOL 2006; 32(1): 32-36 © PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Harvey S. Uy, MD1, 2

Farlah Angela M. Salvosa, MD2

Pik Sha Chan, MD1

Pearl T. Villalon, MD2

1Asian Eye Institute Makati, Philippines

2Sentro Oftalmologico Jose Rizal University of the Philippines-Philippine General Hospital Manila, Philippines

Correspondence to

Harvey S. Uy, MD

Asian Eye Institute

9F Phinma Plaza Building

Rockwell Center

1200 Makati City, Philippines

Telephone : +63-2-8982020

Fax : +63-2-8982002

Email : harveyuy@yahoo.com

No financial assistance was received for this study.

The authors have no proprietary or financial interest in

any product used or cited in this study.

Transpupillarythermotherapy

for central serouschorioretinopathy

PHILIPP J OPHTHALMOL VOL 32 NO. 1 JANUARY - JUNE 2007 33PHILIPPINE ACADEMY OF OPHTHALMOLOGY

CENTRAL serous chorioretinopathy (CSC) is charac-terized by accumulation of exudative fluid under theneurosensory retina resulting in a circumscribed area ofretinal detachment.1-2 Retinal-pigment-epithelium (RPE)hypersecretion, RPE layer discontinuity, choroidalhyperpermeability, and choroidal-circulation abnorma-lities are pathologic mechanisms in the development ofCSC.3-7 Most cases of CSC resolve spontaneously within 4months; however, certain patients experience recurrentor persistent CSC and prolonged visual disturbances.

Focal laser photocoagulation (FLP) can reduce leakageand promote resolution of subretinal fluid, resulting infaster anatomic and visual recovery.8-10 However, choroidalneovascularization (CNV), inadvertent photocoagulationof the fovea, and juxtafoveal scotoma formation arepotentially harmful complications of laser photo-coagulation.6, 11

Photodynamic therapy (PDT) has been shown to beeffective in treating CSC in a small series of patients. PDTis believed to resolve choroidal hyperpermeability whilesparing neuroretinal tissue from thermal damage.12-13

However, patient access to PDT is limited due to the highcost of photosensitizing drug verteporphin.

Transpupillary thermotherapy (TTT) is a treatmentmodality for subfoveal CNV in age-related maculardegeneration. TTT has similar therapeutic effects as PDT,like reduction in angiographic leakage from CNV.14-16

When subthreshold levels of TTT energy are used, onlyminimal changes in the human retina are observed. 17-19

Because of its ability to induce choroidal vascular changesand spare the human retina from thermal damage, TTTis a potential treatment for CSC. We report here our resultsusing TTT for chronic CSC.

METHODOLOGYNine patients with persistent CSC of a least 4 months’

duration were examined at the Asian Eye Institute (AEI)from December 1, 2002 to April 1, 2004. Of these, weexcluded 5 patients with a history of prior ocular disease,steroid intake, or previous laser treatment. We alsoexcluded patients with leakage sites within half-an-optic-disc diameter of the optic-nerve head. Best-correctedvisual acuity (BCVA), slitlamp biomicroscopy, non-contact-lens fundus examination, automated visual-field testing(VF), and indirect ophthalmoscopy were performedduring each visit. The diagnosis of active CSC wasconfirmed by fluorescein angiography (FA) during theinitial visit. FA was performed every 2 months whilesubretinal fluid was clinically visible. Informed consentwas obtained from each patient prior to the start of thestudy. The AEI Institutional Review Board approved thestudy protocol and informed-consent form.

Of the 4 patients enrolled in the study, 3 were male.

The mean age was 44 years (range, 30 to 56). The meanduration of illness was 10 months (range, 7 to 16). Twoof the 4 patients had juxtafoveal lesions and 2 hadextrafoveal lesions. Two patients had fibrin within the areaof neurosensory detachment. One patient (Case 3) hadan inferior retinal detachment. The individual patientcharacteristics are detailed in Table 1.

A 810-nm diode laser (Oculight SLX, Iridex Corp,Mountain View, CA) was used to deliver laser energythrough a slitlamp-mounted large spot adapter. A singleone-minute continuous pulse was applied with a power-diameter ratio of 100 mW/mm2. All treatments were appliedthrough an Area Centralis Fundus/Laser Lens (Volk OpticalCo, Mentor, OH, USA). The treatment area was set at thelarge spot adapter setting (0.5, 0.8, 1.2, 2.0, or 3.0 mm2)closest to but larger than the measured greatest lineardiameter of the angiographic leakage site as measured bythe imaging software of the fundus camera (ImageNet 2000,Topcon, Japan). VF was done using an Octopus 101perimeter (Haag-Streit AG, Koeniz, Switzerland).

The patients were followed up monthly for the first 3months, then quarterly once the lesion had resolved. Fornonresolving lesions, FA was repeated every 2 months;repeat TTT was performed using a power-diameter ratio10% greater than the initial dose. Main outcome measureswere: frequency of successful CSC resolution, resolutiontime, number of treatments, best-corrected visual acuity(BCVA), VF and treatment-related complications. Themean follow-up period was 9 months (range, 5 to 14).

RESULTSThree of the 4 eyes experienced complete resolution

of CSC within 1 month of a single treatment while 1 eyeresolved after 6 months and 3 TTT treatments (Case 3).The mean number of treatments was 1.5 ± 1.0. BCVAimproved in 2 eyes and remained the same in the other 2.VF showed decrease in scotoma size associated with thedisappearance of the neurosensory detachment. Nopatient experienced VF worsening or other treatmentcomplications (Table 1).

Case 1A 49-year-old male reported blurred, distorted vision in

the left eye, which persisted for 9 months. Initial BCVA was20/40. Dilated retinal examination revealed a well-definedarea of macular detachment and RPE changes. VFdemonstrated central and Seidel scotoma. FA revealed 1juxtafoveal leakage site temporal to the fovea. TTT wasoffered to improve patient’s vision. The macular detach-ment resolved 1 month after treatment with recovery ofBCVA to 20/20. Repeat VF showed disappearance of thecentral scotoma. No field defects developed at the site oftreatment. There was a residual Seidel scotoma that

34 PHILIPP J OPHTHALMOL VOL 32 NO. 1 JANUARY - JUNE 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

corresponded to an area of RPEatrophy and not to treatment site(Figure 1).

Case 3A 30-year-old male trauma-service

nurse developed CSC in the left eye 2years before consultation and hadundergone focal laser photo-coagulation of juxtafoveal leakage siteresulting in a central scotoma. A yearbefore consultation, the patientexperienced mild visual distortion inthe right eye which persisted. Dilatedretinal examination and FA revealeda well-circumscribed macular detach-ment containing fibrin, inferiorretinal detachment (RD), and atemporal extrafoveal leakage site. VFshowed a superior scotoma corres-ponding to the inferior RD. TTT wasoffered to resolve CSC withoutproducing a central scotoma. ThreeTTT treatments were applied over afour-month period (Table 1). Sixmonths after TTT, the maculardetachment, fibrin, and inferiorretinal detachment had completelyresolved. Repeat VF showed reduc-tion in central scotoma; however,there was persistence of the superiorarcuate scotoma corresponding tothe area of the RD, possibly indicatingdelayed recovery of neurosensoryretinal function (Figure 2).

DISCUSSIONCSC is a maculopathy charac-

terized by focal serous detachment ofthe neurosensory retina and RPE.

C D

A B

Figure 1. Fundus photograph demonstrating a well-defined neurosensory detachment with foveal involvement (A).

Midphase fluorescein angiogram demonstrating a single juxtafoveal leakage site and patches of retinal pigment epithelial

atrophy (B). Fundus photograph taken one month after treatment demonstrates absence of neurosensory detachment

(C). Posttreatment fluorescein angiogram demonstrates disappearance of the leakage site (D). Visual-field test initially

demonstrates a prominent central scotoma (E). One month after treatment, visual-field test demonstrates reduction in the

size of the central scotoma (F).

E F

Table 1. Patient characteristics, treatment parameters, and outcomes.

Patient

1

2

3

4

Age

(Yrs)

49

42

30

56

Sex

M

F

M

M

Disease

Duration

(months)

9

13

12

16

Leakage

Site

Juxtafoveal

Extrafoveal

Extrafoveal

Juxtafoveal

Other

Retinal

Findings

RPE1 changes

PED2

Fibrin, inferior RD3

Fibrin

Visual-

Field

Change

Improved

Improved

Improved

Improved

Time to

Resolve

(months)

1

1

6

1

Power–

Diameter

Ratio

(mW/mm2)

100

100

100,112,125

100

Spot

Size

(mm2)

0.5

0.5

0.5, 0.8, 0.8

1.2

Laser

Power

(mW)

50

50

50, 90, 100

120

No. of

Treat-

ments

1

1

3

1

Post-

TTT5

BCVA4

20/20

20/25

20/20

20/30

Initial

BCVA4

20/40

20/400

20/20

20/30

Follow-up

(months)

14

8

8

5

1. Retinal pigment epithelium

2. Pigment epithelial detachment

3. Retinal detachment

4. Best-corrected visual acuity

5. Transpupillary thermotherapy

PHILIPP J OPHTHALMOL VOL 32 NO. 1 JANUARY - JUNE 2007 35PHILIPPINE ACADEMY OF OPHTHALMOLOGY

Because of these characteristics, TTTis theoretically advantageous for treat-ing CSC because the pathology of CSCis believed to be at least in part due toRPE hypersecretion and choroidalhyperpermeability.3-7

TTT produces dose-dependentbiological and angiographic effectsprimarily within the pigmented layersof the eye. It has been clinically andexperimentally shown to induce avariety of local-tissue changes thatlead to involution of CNV andreduction of subretinal exudation.These effects are believed to be partlymediated by choroidal expression ofheat shock proteins causing apoptosisof endothelial cells and vascularthrombosis.22, 27 TTT causes anincrease in biological-tissue tempera-ture of 8 to10° Celsius in comparisonto conventional FLP, which produceslarger temperature increases of 40 to60° Celsius. The relatively smallincrease in tissue temperature usingTTT is believed to spare theneurosensory retina from thermaldamage.19, 22 In this small series, allCSC patients experienced closure ofleakage sites. No patient experiencedthermal-related treatment compli-cations such as scar or scotomaformation.

TTT induces vascular changessimilar to PDT such as transientlyreduced retinal-blood flow, increasedchoroidal-vascular leakage within 1hour after treatment and disappear-ance of choroidal leakage 1 to 2weeks after treatment.15 Comparedwith PDT, TTT avoids photosensitizer-related complications such as skinburns. TTT is cheaper since anexpensive photosensitizing dye is notused.

The complications of TTT for CNVtreatment are dose-dependent andinclude macular burn, hemorrhage,RPE tear, progressive subretinalfibrosis, vascular proliferation, andRPE atrophy. The amount of tissue-absorbed laser energy is affected bylaser power, treatment duration,

A B

C

FE

D

Figure 2. Fundus photograph demonstrating a large neurosensory detachment in the temporal macula containing fibrin

(A). Midphase fluorescein angiogram demonstrating smoke-stack pattern of leakage from a single juxtafoveal leakage

site and a small pigment epithelial detachment within the papillomacular bundle (B). Fundus photograph taken six months

later, after three treatment applications, demonstrates complete absence of neurosensory detachment (C). Posttreatment

fluorescein angiogram demonstrates disappearance of the leakage site, retinal pigment epithelium atrophy and persistent

pigment epithelial detachment (D). Visual-field test initially demonstrates a superior arcuate and central scotoma close to

fixation (E). Visual-field test after six months demonstrates disappearance of the central scotoma closest to fixation point

and persistence of the superior scotoma (F).

While most cases spontaneouslyresolve within 2 to 3 months,prolonged pigment epithelial detach-ment or subretinal fluid may lead topermanent visual-acuity loss andvisual disturbances.23 FLP can shortenthe clinical course and hasten visualrecovery.8, 9 It can also improve finalvisual outcome and prevent recur-rences.10 However, FLP of subfovealand juxtafoveal leakage sites can

cause loss of contrast sensitivity andsight-threatening complications suchas juxtafoveal scotoma, subfoveallaser scarring, and CNV.24, 25 Extra-foveal FLP and PDT are less damagingtreatment alternatives.12, 26

The 810-nm, near-infrared laserbeam used in TTT is mainly absorbedby the choroidal melanocytes and RPEmelanin and is poorly absorbed by reti-nal tissues and hemoglobin.20-22

36 PHILIPP J OPHTHALMOL VOL 32 NO. 1 JANUARY - JUNE 2007 PHILIPPINE ACADEMY OF OPHTHALMOLOGY

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